5.01 INTRODUCTION

Pursuant to 5 M.R.S. §§ 8054 and 8073, this single emergency rulemaking implements temporary changes to various sections of the MaineCare Benefits Manual (MBM) in order to expedite and improve access to medical care for MaineCare members in light of the substantial public health threat posed by the Novel Coronavirus (COVID-19).

The following sections of MaineCare policy are affected by this rulemaking: Ch. 1, Section 1 (General Administrative Policies and Procedures); Ch. I, Section 4 (Telehealth Services); Chs. II and III, Section 31 (Federally Qualified Health Center Services); Chs. II and III Section 40 (Home Health Services); Chs. II and III, Section 45 (Hospital Services); Ch. II, Section 55 (Laboratory Services); Ch. II, Section 60 (Medical Supplies and Durable Medical Equipment); Chs. II and III, Section 65 (Behavioral Health Services); Ch. II, Section 80 (Pharmacy Services); Ch. II, Section 90 (Physician Services); Chs. II and III, Section 96 (Private Duty Nursing and Personal Care Services); Ch. II, Section 101 (Medical Imaging); and Chs. II and III, Section 103 (Rural Health Clinic Services).

In the event of conflict between the COVID-19 Public Health Emergency Services rule and any other MaineCare rule, the terms of this rule supersede other rules and shall apply.

The Department shall seek and anticipates receiving approval of these changes from the Centers for Medicare and Medicaid Services (CMS) retroactive to March 18, 2020.

Except as noted herein, these changes shall be effective for ninety (90) days, per 5 M.R.S. § 8054.

5.02 CO-PAYMENTS

The Department waives co-payments for the following MaineCare services for all MaineCare members:

A. Pharmacy: All co-payments charged by pharmacies under Section 80, Pharmacy Services.

B. Clinical Visits: MaineCare currently requires some members to pay a co-payment for clinical visits based on the member's eligibility coverage group. All co-payments for clinical visits for MaineCare members, regardless of eligibility coverage group, are waived. This includes, but is not limited to, Hospital Services (Sec. 45), Federally Qualified Health Center Services (Sec. 31), Rural Health Clinic Services (Sec. 103), Physician Services (Sec. 90).

C. Medical Imaging Services: All co-payments charged under Section 101, Medical Imaging Services.

D. Laboratory Services: All co-payments charged under Section 55, Laboratory Services.

E. Behavioral Health Services: All co-payments charged under Section 65, Behavioral Health Services.

5.02 CO-PAYMENTS (cont.)

F. Medical Supplies and Durable Medical Equipment: All co-payments charged under Section 60, Medical Supplies and Durable Medical Equipment.

G. Home Health Services: All co-payments charged under Section 40, Home Health Services.

H. Should COVID-19 specific treatments and/or vaccines become available during the duration of this public health emergency rule, co-payments will be waived.

5.03 PHARMACY SERVICES

The Department alters certain provisions of the MBM, Section 80, Pharmacy Services, as follows:

A. Initial Prior Authorization requirements for asthma and immune-related prescriptions: Restrictions on asthma related medications like Albuterol are removed to allow all forms of Albuterol without Prior Authorization. Restrictions on Immune- related medications, like Neupogen, are removed for approval with completion of Prior Authorization form, if necessary, for the treatment of COVID-19.

B. COVID-19 Treatments or Vaccines: Should COVID-19 specific treatments or vaccines become available during the duration of this emergency rule, Prior Authorization will be waived.

C. Prescription Refills: Early refills of prescription medications are allowed in the same days' supply and quantity as the original prescription; the requirements set forth in Ch. II, Sec. 80.07-7 are waived.

D. Buprenorphine and Buprenorphine Combination Products for Substance Use Disorder (SUD): The physical assessment requirements for Buprenorphine and Buprenorphine Combination Products for SUD set forth in Ch. II, Sec. 80.07-13 are waived.

5.04 MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT

A. COVID-19-Related Supplies and Durable Medical Equipment: Prior Authorization approvals currently in effect for Section 60, Durable Medical Equipment (DME), will be extended for individuals with COVID-19 (who should be in quarantine), individuals with pending COVID-19 tests in self-isolation, and individuals in the high-risk category for developing severe complications from COVID-19, and early refills will be temporarily allowed as follows on the following DME items:

1. Glucose supplies;

2. Hearing aid batteries; and

5.04 MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT (cont.)

3. The following Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (Bi-PAP) supplies:

a. Oral/nasal mask - one (1) per three (3) months;

b. Oral cushion - two (2) per one (1) month;

c. Nasal pillow - two (2) per one (1) month;

d. Full face mask - one (1) per three (3) months;

e. Facemask interface - one (1) per one (1) month;

f. Nasal interface - two (2) per one (1) month;

g. Tubing - one (1) per one (1) month;

h. Tubing (with heating element) - one (1) per three (3) months;

i. Filter (disposable) - two (2) per one (1) month;

j. Oral interface - one (1) per three (3) months; and

k. Water chamber - one (1) per one (1) month.

B. Extension of Prior Authorizations set to end will be temporarily allowed, when applicable, for the following:

1. CPAP and Bi-PAP devices and supplies;

2. Home blood glucose monitors and test strips;

3. Enteral and Parenteral nutritional therapy;

4. Apnea Monitors;

5. External Insulin Infusion Pumps;

6. Infusion Pumps Other than Insulin Pumps;

7. Continuous Glucose Monitors; and

8. Home Use of Oxygen.

5.05 HOME HEALTH SERVICES*

The Department extends the period of time for Home Health Providers to submit Plans of Care to the Department under MBM, Ch. II, Section 40, Home Health Services, § 40.02-1, Authorization Process. The current requirement of submission within five (5) business days is extended to within thirty (30) business days, including for certifications and recertifications.

*MBM, Chs. II and III, Section 40, Home Health Services, are major substantive rules, thus, if CMS approves, these emergency rules changes shall be effective for up to one year pursuant to 5 M.R.S. § 8073.

5.06 TELEHEALTH

A. Waiver of Advance Written Notice.

The Department is waiving the requirement under Ch. 1, Section 4, Telehealth, Sec. 4.06-2.B, requiring advance written notice/consent prior to services.

5.06 TELEHEALTH (cont.)

B. Waiver of Comparability

The Department, at its discretion, may waive the requirement under Ch. 1, Section 4, Telehealth, Sec. 4.04-1(2), requiring Interactive Telehealth Services be of comparable quality to what they would be were they delivered in person. Requests will be handed on a case-by-case basis through a clinical review by the Department to determine whether members may face imminent harm in the absence of a telehealth mode of delivery for a particular service, given the inability due to the public health emergency for that member to receive the service in-person

C. Telephone-Only Evaluation and Management.

The Department will reimburse providers for telephone evaluation and management services provided to members. The restrictions set forth in the MaineCare Benefits Manual, Ch. I, Sec. 4.04-2 are waived for this purpose.

Telephonic evaluation and management services must be rendered by a qualified professional actively enrolled in MaineCare or contracted through an enrolled MaineCare provider.

Relevant CPT codes are:

• 99441: Telephone evaluation and management service; 5-10 minutes of medical discussion

• 99442: 11-20 minutes of medical discussion

• 99443: 21-30 minutes of medical discussion

Telephone evaluation management services are not to be billed if clinical decision-making dictates a need to see the member for an office visit within 24 hours or at the next available appointment. In those circumstances, the telephone service shall be considered a part of the subsequent office visit. If the telephone call follows an office visit performed and reported within the past seven (7) days for the same diagnosis, then the telephone services are considered part of the previous office visit and are not separately billable.